Cardiac Arrest Patients Don’t Necessarily Do Better With Intubation

Patients with out-of-hospital cardiac arrest (OHCA) fared similarly whether paramedics took one approach to advanced airway management or another, the Taiwanese SAVE trial showed.

Clinical outcomes were generally no different between groups subject to the initial strategies of endotracheal intubation or supraglottic airway device insertion:

• Sustained return of spontaneous circulation (ROSC) 2 hours after resuscitation: 26.9% vs 25.8% (OR 1.02, 95% CI 0.98-1.06)

Only prehospital ROSC suggested an advantage to standard endotracheal intubation (10.6% vs 6.4%; OR 1.04, 95% CI 1.02-1.07), according to Wen-Chu Chiang, MD, PhD, of National Taiwan University Hospital in Taipei City, and colleagues, reporting in JAMA Network Open.

One drawback of endotracheal intubation is the difficulty in getting it right: the SAVE paramedics, all experienced in both methods of advanced airway management, employed direct laryngoscopy (not video laryngoscopy) and achieved a 77% rate of first-attempt airway success with endotracheal intubation (vs 83% with the supraglottic device).

Chiang’s group also reported that scene time (mean 18.4 vs 16.9 minutes) and call-to-airway time (15.9 vs 13.9 minutes) were both longer with endotracheal intubation in the study.

“It is unclear whether a stepwise and algorithmic endotracheal intubation training program could reduce the time in the field and the time for advanced airway insertion, and further research is warranted,” the authors said.

SAVE was a multicenter cluster-randomized trial conducted in Taipei City from 2016 to 2019.

The results may have variable applicability stateside, suggested Andrew McCoy, MD, MS, the EMS fellowship director at the University of Washington School of Medicine in Seattle, who was not involved with the research.

“Current airway management strategies in the U.S. vary by EMS system. State and local protocols, baseline and continuing training differences, along with a myriad of other factors, play a role in the differences that exist between systems in their management of airway in OHCA,” McCoy commented.

“Taipei City is a high performing EMS system that compares well with high performing agencies in the U.S. Paramedic training, deployed equipment, and treatment philosophies are similar to the upper echelon of American systems,” he told MedPage Today.

For the trial, Chiang and co-authors had four EMS teams randomly split into two clusters, each assigned to initial endotracheal intubation or supraglottic i-gel device insertion when responding to OHCAs over a biweekly period. In case the first advanced airway attempt failed, rescue airway management was allowed using a number of techniques.

The 936 OHCA patients in the study had a median age of 77 years, and 60.8% were men.

On subgroup analysis, it appeared that prehospital ROSC rates favored endotracheal intubation in patients with nonshockable rhythm, nonpublic collapse, witnessed arrest, call-to-airway time under 14 minutes, and age 77 years or older.

Yet SAVE left room for different in-hospital management between groups, which could have affected the results.

Chiang and colleagues also acknowledged that the two study arms comprised uneven numbers of patients, and that the trial could have been underpowered due to inaccurate sample size estimation at the beginning of the study.

“However, even if we had realized that the sample size was inadequate at that time, we would not have been able to recruit more cases because of the outbreak of COVID-19,” the team lamented.

“The study authors deserve credit for a well designed and executed study of an important topic,” McCoy said. “The results of this trial are likely to add continued fuel to the fire of the debate in the U.S. between supraglottic airways and endotracheal tubes in the treatment of patients with OHCA.”